Guideline for Concussion/Mild Traumatic

Brain Injury and Persistent Symptoms

3rd

Edition - for adults, +18 years of age

Patient Version

This guideline has been created to help with management of

concussion/mild traumatic brain injury (mTBI). It is only for

management for adults over 18 years of age. The guideline can

be used by patients when speaking with healthcare providers

about their care. It covers getting a diagnosis, managing

symptoms in the early phase (acute) and management in the

longer recovery phase (persistent symptoms). It is based on up-

to date, quality research evidence, the expertise of providers

and the input of patients.

Guidelines for Concussion/mTBI and Persistent Symptoms - Patient Version Page 1

6) Post Traumatic Headache

Headache is the most common symptom after a concussion/ mTBI. Post-

traumatic headaches can last for a long time. They can affect your ability to go to

school, work, do your daily activities, and interact with others.

People with post-traumatic headaches can have different

types of symptoms. Some headaches feel like a migraine,

others feel like a tension-type headache. In the majority of

people, these headaches stop after a few days or weeks. But

sometimes they can last for months or longer.

How does the doctor diagnose my headache?

It is a good idea to keep a headache diary or calendar that you can bring with you

when you see your doctor. This will give the doctor more

information about your headaches, when you are having them and

how bad they are. An example headache diary has been

included. This information will help the doctor understand what

type of headache you have and how to manage it.

Your doctor may ask several questions to better understand the type of

headaches you have:

How often do you get headaches?

How long do they last?

Where do you feel the pain?

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How strong is the pain?

What type of pain do you feel (such as pressure, throbbing, stabbing)?

Do you have other symptoms (such as nausea or vomiting)?

Does anything trigger your headaches?

Is there anything that helps relieve the pain?

Did you have previous treatments? Did they improve your symptoms or

have side effects?

Do your headaches affect your ability to function (such as do your work, go

to school, attend social events, do hobbies, or get out of bed)?

Your doctor may also do other tests, or make a referral to a specialist to figure out

what might be causing your headaches. For example:

A neurologic exam to find out if there is injury to your brain or nerves.

A cervical spine and musculoskeletal exam to look for any injury to your

jaw, neck, or other parts of your head.

A vestibular exam to look for any damage to your inner ear.

What can I do to prevent headaches?

There are some things you can do to help prevent headaches:

Get enough sleep Go to bed and wake up at the same times every

day.

Avoid naps during the day.

If you often have difficulty falling or staying asleep,

Please read Section 7 on “Sleep-Wake

Disturbances”.

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Eat regular meals Try not to skip breakfast, lunch or dinner, and eat

at regular times.

Try to have protein at every meal.

Stay hydrated Drink 4 to 6 glasses of water every day.

Avoid caffeine in coffee, tea, or soft-drinks, and

diet drinks that contain aspartame.

Keep in mind that if you are a regular caffeine

drinker, stopping suddenly could trigger a

headache.

Avoid stress Try relaxation activities to help you deal with

stress, such as meditation, yoga, and exercise.

If you have difficulty managing stress, talk to your

doctor.

Get regular

exercise

If your doctor says you can start to exercise, go for

brisk walks, go swimming, or use an exercise

machine every day.

Start slowly and increase your effort gradually.

If exercise triggers a headache, reduce your effort

or try a different activity.

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How can I manage my headaches without medication?

Here are some things you can do to help manage your headaches:

Apply a cold or hot pack to your neck or head.

Stretch and self-massage your head, neck, and shoulders.

Do breathing exercises.

Go to a quiet place.

Lie down.

Go outside to get fresh air.

Do visualization or other mindfulness-based exercises (you may need to

see someone to learn how to do these).

What medications will my doctor prescribe?

Your doctor may prescribe acute therapy and prophylactic therapy with

medications called analgesics. Analgesics are designed to relieve pain.

Acute analgesics can help get rid of a headache, or at least stop it from

getting worse.

Preventive (or prophylactic) analgesics are taken before a headache starts.

They do not cure headaches, but can reduce their frequency or intensity.

They can also make headaches more likely to respond to acute therapy.

Preventive analgesics can take a few weeks to work, so you may need to use

them for at least 12 weeks, unless you have side effects that you feel are difficult

to tolerate.

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Always follow your doctor’s instructions on how to take your medication. If you

use an analgesic for longer than your doctor recommends, it may trigger a

rebound headache. Rebound headaches can come from regular, long-term use

of analgesics. The only way to treat a rebound headache is to stop taking the

analgesic that caused it.

It is a good idea to use a headache diary or calendar to record your symptoms,

the time that you took your medication, and any activities that may have triggered

or stopped a headache.

TOOLS AND RESOURCES

Appendix 6.4 Headache Diary

Appendix 6.6 Self-Regulated Intervention and Lifestyle Strategies

List of medications for different persistent symptoms

Guidelines for Concussion/mTBI and Persistent Symptoms: 3rd Ed.

Section 1 2 3 4 5 6 7 8 9 10 11 12 Table of Contents

Appendix 6.4Headache Diary

Guidelines for Concussion/mTBI and Persistent Symptoms: 3rd Ed.

Section 1 2 3 4 5 6 7 8 9 10 11 12 Table of Contents

Appendix 6.6

Self-Regulated Intervention and Lifestyle Strategies to Minimize Headache Occurrence

Simple Self-regulated Intervention Strategies*

• Apply a cold or hot back to the neck or head• Tie something tight around the head• Stretching and self-massaging the head and/or neck and shoulders• Perform breathing exercises• Visualization or other mindfulness-based exercises• Go to a quiet place• Lie down• Go outside to get fresh air

* Note. When relevant, there are a variety of allied-health professionals who can guide individuals to perform appropriatehome-based neck and shoulder stretching.

Lifestyle Strategies to Minimize Headache Occurrence

a) Sleep: It is well-known that sleep deprivation or inconsistent sleep-wake cycles can precipitate headaches orpreclude improvement. Accordingly, it is important to educate individuals with post-traumatic headache (PTH) on theimportance of going to bed at the same time each night and waking up at the same time each night and, if possible,avoiding day-time naps. If insomnia continues to be a significant problem, please refer to section 7 for an approach tothe management of insomnia

b) Regular Meals: It is well-known that skipping or delaying meals can trigger headaches in some people. As such, it isimportant to ensure that patients with PTH consume breakfast (ideally a high-protein breakfast), lunch and dinner andavoiding delaying or skipping meals.

c) Hydration: It is thought that dehydration can be a trigger for headaches in some susceptible individuals. As such, it isimportant to maintain good hydration – this means consuming 4-6 drinks per day of water, juice, milk or other non-caffeinated beverages. Regular daily caffeine-consumption (i.e., coffee, soft-drinks) should be avoided as caffeineconsumption and withdrawal can precipitate headaches (when an individual does not consume caffeinated beveragesregularly, a caffeinated beverage may be helpful to minimize intermittent bad headaches). Diet soft-drinks should befurther avoided as, in some, aspartame may trigger headaches.

d) Stress: It is well-known that in many individuals stress, worry, anxiety or anger can be a significant trigger forheadaches. These symptoms are particularly common in individuals who have sustained a traumatic brain injuryand, as such, can have a major impact on the frequency and severity of PTH. As such, using relaxation strategies,doing activities such as meditation, yoga, and exercise can assist with coping with stress and avoiding stress-induced worsening of headaches. The assistance of an occupational therapist, psychologist, GP-psychotherapist orpsychiatrist may be necessary.

e) Exercise: In the initial period after a traumatic brain injury, physical rest is often endorsed. However, as the weeksgo by, inactivity is frequently counter-productive and a sedentary lifestyle without any cardiovascular exercisemay, in some, perpetuate the headaches. Accordingly, a brisk walk (particularly a morning walk outside), riding astationary bicycle, walking or jogging on a treadmill or elliptical machine or swimming can be very helpful in headachemanagement. An exercise program should be undertaken as tolerated with gradually increasing duration andintensity. For some, exercise triggers a headache and in these individuals the intensity and/or duration of the exerciseshould be reduced or an alternative exercise should be trialed.

List of medications for different persistent symptoms

There are various medications that could help manage your persistent symptoms. The list

below includes the different options that your doctor may use to manage your symptoms of

concussion or mild traumatic brain injury.

Post-Traumatic Headache

Depending on the type of headache you have your doctor may prescribe one or more

analgesics. For example:

Acetylsalicylic acid (Aspirin)

Acetaminophen (Tylenol)

Ibuprofen (Motrin or Advil)

Combination analgesics (such as codeine or caffeine)

Diclofenac (Voltaren)

“Triptan” medications (such as almotriptan, eletriptan, sumatriptan, rizatriptan, and

zolmitriptan)

Your doctor may also prescribe other medications:

Blood pressure medications (such as nadolol, propranololverapamil)

Epilepsy treatments (such as divalproex, topiramate, gabapentin, and pregabalin)

Antidepressants (such as amitriptyline, nortriptyline, venlafaxine, and duloxetine)

Other types of medications (such as Botulinum toxin injections)

Sleep-Wake Disturbances

Depending on the type of sleep-wake problems you’re having, your doctor may recommend or

prescribe one or more of the following medications:

Magnesium, zinc or melatonin

Medications to prevent daytime sleepiness (such as modafinil)

Antidepressants (such as trazodone, amitryptyline, doxepine, and mirtazapine)

Sleep medications (such as zopiclone)

Blood pressure medications (such as prazosin)

Mental Health Disorders

Depending on the type of mental health disorder that you have, your doctor may prescribe one

or more of the following medications:

Selective serotonin reuptake inhibitors (also known as SSRIs, such as sertraline,

escitalopram, citalopram, and paroxetine)

Serotonin norepinephrine reuptake inhibitors (also known as SNRIs, such as venlafaxine

and duloxetine)

Other types of antidepressants (such as mirtazapine, amitriptyline, imipramine, doxepin,

trazodone)